Negative payoffs of upper gastrointestinal endoscopy in patients admitted under observation status.

BACKGROUND: More than 70 million Americans (23% of the USA population) have non-cardiac chest pain at least once in their lifetime with gastroesophageal reflux disease being the leading cause (37-66%). Current guidelines support the use of a proton pump inhibitor (PPI) prior to invasive or noninvasive testing as a diagnostic, therapeutic and cost-effective method as a part of High Value Care recommendations. METHODS: We performed a chart review of 126 patients admitted to the hospital under observation status who underwent upper gastrointestinal endoscopies in the hospital at 3 different urban community hospitals. This was compared with 260 patients admitted who did not have this procedure done. We calculated the healthcare burden including length of stay, reimbursement and complications from the procedures/extra stay in the hospital. RESULTS: The direct cost per case was almost two times in the group that underwent the procedure as compared to the group that did not. The mean length of stay was higher in the group that underwent the endoscopies. There were no complications and there was no difference in mortality. CONCLUSIONS: Upper gastrointestinal endoscopy in patients with atypical chest pain of gastrointestinal origin as an initial step is a significant healthcare burden and contradicts the currently recommended High Value Care recommendations. Our study delineates this large negative financial impact when performing upper endoscopies under observation status. Such patients should be started on an empirical trial of PPI, and endoscopy should be reserved for patients whose symptoms are unresponsive to PPIs or have alarm features.

Metastatic Cutaneous Melanoma of the Gallbladder.

Metastatic melanoma is an aggressive disease that can spread to many organs of the body. In rare cases, it can spread to the gallbladder causing secondary lesions, yet presenting with little to no symptoms. Therefore, most cases of metastatic melanoma lesions to the gallbladder go undiagnosed. Here, we present the case of a 41-year-old male with a four-month history of melanoma of the face, with a postresection status, who presented with right upper quadrant abdominal pain. Doppler ultrasound and computed tomography confirmed the presence of a mass on the gallbladder. Laparoscopic excision along with liver wedge resection was performed. Pathology staining revealed the presence of a malignant metastatic melanoma lesion of the gallbladder.

Exudative retinopathy and detachment: a late reactivation of retinopathy of prematurity after intravitreal bevacizumab.

A 25-week postmenstrual age premature infant was treated with bilateral intravitreal bevacizumab for retinopathy of prematurity at 35 weeks' PMA. Postinjection, the retinal vessels progressed anteriorly within the retina. The patient presented 1 year after injection with bilateral exudative retinal detachments. The right eye was treated with intravitreal bevacizumab, laser ablation, and scleral buckling, resulting in resolution of the exudation and detachment. The left eye was treated with vitrectomy and lensectomy, but persistent exudation and detachment remained. This case demonstrates the rare complication of exudative retinal detachment in the setting of retinopathy of prematurity, which may become more common with increasing use of bevacizumab. Importantly, it also demonstrates the need not only for frequent examination after bevacizumab injection for retinopathy of prematurity but long-term follow-up as well, until either the retina is fully vascularized or peripheral ablation is performed.

Neurodevelopmental Outcomes after Pediatric Cardiac ECMO Support.

PURPOSE: To characterize the neurodevelopmental outcomes and identify factors associated with poor outcomes in pediatric patients undergoing cardiac extracorporeal membrane oxygenation (ECMO). METHODS: Five year retrospective review, including demographics, cardiac lesion, and surgical complexity, reason for ECMO, ECMO complications, and neurodevelopmental status at discharge and latest follow-up. Neurodevelopmental status was determined through the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category Scales. RESULTS: Overall ECMO survival was 73% at hospital discharge and 66% a t the latest follow-up. Most patients underwent cardiopulmonary resuscitation (CPR) (43%), and the majority (53%) had a significant disease complexity (Aristotle = 4). Complications occurred in 42% of the ECMO runs, of which 12% were intracranial injuries. At hospital discharge, 75% of patients had normal to mild disability, improving to 81% at 2 years follow-up. At hospital discharge, moderate to severe disability was associated with CPR, plasma exchange or intracranial insults. After discharge, 23% showed improvement in neurologic status and 4% showed deterioration. Cerebral infarction was the only parameter associated with deterioration at the later follow-up stage. CONCLUSION: Extracorporeal membrane oxygenation was successfully used in children with cardiac disease with 73 and 66% short and long-term survival respectively. Majority of the survivors had normal to mild neurodevelopmental disability and a significant portion showed neurologic improvement by the latest follow-up. Nevertheless, despite the grossly favorable outcomes standardized comprehensive neuropsychological testing is of paramount importance in all these patients.

Reactivation of retinopathy of prematurity after bevacizumab injection.

OBJECTIVE: To report late reactivation and progression of retinopathy of prematurity (ROP) after intravitreal bevacizumab monotherapy. METHODS: Retrospective review of 9 patients (17 eyes) with recurrence of ROP after initial treatment with intravitreal bevacizumab monotherapy. Data collected included (1) location and stage of ROP activity, (2) number and timing of treatments, and (3) structural outcomes. RESULTS: Mean age at treatment-requiring recurrence was 49.3 weeks (SD, 9.1 weeks; minimum, 37 weeks; maximum, 69 weeks) postmenstrual age (PMA). The mean time between initial treatment and treatment-requiring recurrence was 14.4 weeks, with a minimum of 4 and maximum of 35 weeks. Fives eyes progressed to retinal detachment (4 eyes stage 5, 1 eye stage 4a). Age at retinal detachment ranged from 49 to 69 weeks PMA with a median of 55 weeks PMA and mean of 58.4 weeks PMA. No eye that received laser treatment for recurrence progressed to retinal detachment. CONCLUSIONS: Although intravitreal bevacizumab treatment is effective in inducing regression of ROP, the effect may be transient. Recurrence can occur later in the course than with conventional laser therapy. Late retinal detachment can occur despite early regression. Longterm favorable structural outcome may require extended observation and retreatment. Laser may be a useful treatment for recurrences.

Topical ophthalmic moxifloxacin elicits minimal or no selection of fluoroquinolone resistance among bacteria isolated from the skin, nose, and throat.

PURPOSE: To investigate whether moxifloxacin therapy of bacterial conjunctivitis in children changes the moxifloxacin susceptibility of bacterial isolates in eyes, cheeks below eyes, nares, and throat. METHODS: Patients (age: 1 to 12 years, n = 105) with bacterial conjunctivitis were treated topically with moxifloxacin three times a day for 7 days. Gender- and age-matched subjects with normal eyes (age: 1 to 12 years, n = 57) served as the control group. Microbiological specimens were collected on days 1 (prior to therapy), 8 (1 day after end of therapy), and 42 (follow-up). Specimens were processed to recover total bacteria and bacteria that grew on fluoroquinolone-selective media. Bacteria were identified to the species level and susceptibility to moxifloxacin and selected other antibiotics determined. RESULTS: The primary pathogens recovered from the infected eyes on day 1 before therapy were Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. None of the pre-therapy isolates of H. influenzae and S. pneumoniae were resistant to moxifloxacin. Isolates of these two pathogenic species were also recovered primarily from the nose and eyes. Moxifloxacin-resistant S. aureus isolates (minimum inhibitory concentration 1.0 µg/mL or greater) were recovered from the nose and throat prior to topical dosing on day 1. However, there was no change in the frequency of moxifloxacin-resistant isolates of S. aureus following treatment with moxifloxacin. CONCLUSION: Treatment of conjunctivitis with topical ophthalmic moxifloxacin did not select for moxifloxacin resistance in H. influenzae, S. pneumoniae, or S. aureus in the eye or distal body sites.

Small cell carcinoma: an unusual location in a young healthy female.

Small cell carcinoma (SCC) is most commonly found in the lung but is occasionally found in the gastrointestinal tract and other extrapulmonary sites. Incidences of SCC in the esophagus and stomach are rare and have been reported almost exclusively in older individuals. The following case presents the discovery of small cell carcinoma of the stomach and esophagus in a 35 year old woman, which is the youngest reported incidence of this to date. Additionally, her course reflects the importance of early diagnostic endoscopy with biopsy and adequate sampling with appropriate immunohistochemical staining when malignancy is in the differential diagnosis, regardless of age or risk factors.

Perioperative use of dexmedetomidine is associated with decreased incidence of ventricular and supraventricular tachyarrhythmias after congenital cardiac operations.

BACKGROUND: Postoperative tachyarrhythmias remain a common complication after congenital cardiac operations. Dexmedetomidine (DEX), an α-2 adrenoreceptor agonist, can have a therapeutic role in supraventricular tachyarrhythmias for cardioversion to sinus rhythm or heart rate control. Whether routine perioperative use of DEX decreases the incidence of supraventricular and ventricular tachyarrhythmias was studied. METHODS: In this prospective cohort study, 32 pediatric patients undergoing cardiothoracic operations received DEX and were compared with 20 control patients who did not receive DEX. RESULTS: Dexmedetomidine was started after anesthesia induction and continued intraoperatively and postoperatively for 38±4 hours (mean dose, 0.76±0.04 µg/kg/h). Ten control patients and 2 DEX patients sustained 16 episodes of tachyarrhythmias (p=0.001), including a 25% vs 0% (p=0.01) incidence of ventricular tachycardia and 25% vs 6% (p=0.05) of supraventricular arrhythmias in the control and DEX group, respectively. Transient complete heart block occurred in 2 control patients and in 1 DEX patient. Control patients had a higher heart rate (141±5 vs 127±3 beats/min, p=0.03), more sinus tachycardia episodes (40% vs 6%; p=0.008), required more antihypertensive drugs with nitroprusside (20±7 vs 4±1 µg/kg; p=0.004) and nicardipine (13±5 vs 2±1 µg/kg; p=0.02), and required more fentanyl (39±8 vs 19±3 µg/kg; p=0.005). CONCLUSIONS: Perioperative use of dexmedetomidine is associated with a significantly decreased incidence of ventricular and supraventricular tachyarrhythmias, without significant adverse effects.

Electrocardiographic effects of dexmedetomidine in patients with congenital heart disease.

OBJECTIVE: Assessment of electrocardiographic (ECG) effects of dexmedetomidine. DESIGN: Prospective observational study including children 0-17 years of age with congenital heart disease (CHD) and children following cardiothoracic surgery. Patients who did not receive dexmedetomidine were used as a control group. All patients had two ECGs: one baseline, pre-dexmedetomidine (T1) and one during dexmedetomidine infusion (T2). MEASUREMENTS AND RESULTS: Fifty-one patients, median age of 0.5 years (IQR = 3.4), and 25 patients, age 0.25 (IQR = 2.9), were included in the dexmedetomidine and control groups, respectively. Forty received a dexmedetomidine-loading dose of 1 microg/kg (IQR = 0.5). At T2, the dexmedetomidine infusion was 1 microg/kg/h (IQR = 0.5). In the dexmedetomidine group, heart rate (HR) decreased from 140 +/- 22 to 115 +/- 23 (P < 0.001); PR, PRc and PR index changed from 115 +/- 28 to 122 +/- 29 ms (P = 0.01), 174 +/- 38 to 167 +/- 35 ms (P = 0.07) and 15,882 +/- 3,565 to 13,792 +/- 3,311 (P < 0.001), respectively. QRS decreased from 84 +/- 21 to 80 +/- 21 ms (P = 0.02), and QTc had no change (433 +/- 47 to 435 +/- 36 ms). When compared to the control group, none of the ECG intervals had any difference other than a trend towards lower HR (P = 0.08). Neonates and infants had a bigger drop in the HR compared to older children (P < 0.001), while other parameters were similar. At T2 none of the dexmedetomidine group patients had atrioventricular block or other arrhythmia. Four patients in the control group had accelerated junctional rhythm. CONCLUSIONS: Use of dexmedetomidine in patients with CHD and patients following cardiothoracic surgery is not associated with any significant ECG interval abnormalities other than a trend towards lower HR.

Kinetics of kill of bacterial conjunctivitis isolates with moxifloxacin, a fluoroquinolone, compared with the aminoglycosides tobramycin and gentamicin.

PURPOSE: To compare the kinetics and speed of kill of Streptococcus pneumoniae and Haemophilus influenzae on exposure to three topical ophthalmic antibiotic solutions. MATERIALS AND METHODS: Bacterial conjunctivitis isolates of S. pneumoniae and H. influenzae were exposed to 1:1000 dilutions of moxifloxacin 0.5%, tobramycin 0.3%, gentamicin 0.3%, and water (control). At 15, 30, 60, 120, and 180 minutes after exposure, aliquots were collected, cells were cultured, and viable cell counts were determined using standard microbiological methods. RESULTS: Moxifloxacin achieved 99.9% kill (3-log reduction) at approximately 2 hours for S. pneumoniae and at 15 minutes for H. influenzae. Tobramycin and gentamicin did not achieve 3-log reduction of S. pneumoniae during the 180-minute study period. An increase in bacterial growth was noted for these isolates. Gentamicin took more than 120 minutes to achieve the 3-log reduction of H. influenzae and tobramycin did not reach the 3-log reduction of this pathogen during the 180-minute study period. CONCLUSION: Moxifloxacin killed S. pneumoniae and H. influenzae in vitro faster than tobramycin and gentamicin, suggesting its potential clinical benefit as a first-line treatment for bacterial conjunctivitis to minimize patient symptoms and to limit the contagiousness of the disease.

Effect of dexmedetomidine on pulmonary artery pressure after congenital cardiac surgery: A pilot study.

OBJECTIVE: To characterize the effects of dexmedetomidine on the pulmonary artery pressure in patients after congenital cardiac surgery. DESIGN: Prospective observational pilot study. SETTING: Pediatric cardiac intensive care unit at a university hospital. PATIENTS: Twenty-two patients who received dexmedetomidine after cardiothoracic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: An echocardiogram was performed at three time points: 1) baseline (T0); 2) 6 mins after dexmedetomidine loading (T1); and 3) 1 hr after initiation of dexmedetomidine infusion (T2). Transthoracic echocardiography was used to estimate pulmonary artery pressure based on tricuspid regurgitant velocity (4 x Velocity2) plus central venous pressure. Twenty-two patients aged 0.9 yrs old (interquartile range, 7.9) were enrolled at a median of 1 hr (1.5) after surgery. Dexmedetomidine loading, 0.62 microg/kg (0.5), was given in all patients followed by 0.5 microg/kg/hr (0.6) at T1 and 0.65 microg/kg/hr (0.5) at T2. None of the patients had any increase in pulmonary artery pressure. Overall, the pulmonary artery pressure decreased from 30 mm Hg (13) at T0 to 24 mm Hg (10) at T1 and 26 mm Hg (8) at T2 (p < .001). The pulmonary artery pressure/systemic systolic blood pressure ratio decreased from 33% (12) at T0 to 23% (15) at T1 and 25% (13) at T2 (p = .002). There was no difference in the left ventricular function, Fio2, oxygen %, Po2, CO2, and vasoactive agents. CONCLUSIONS: Administration of dexmedetomidine after congenital cardiac surgery was not associated with any increase in pulmonary artery pressure.

Magnesium supplementation during cardiopulmonary bypass to prevent junctional ectopic tachycardia after pediatric cardiac surgery: a randomized controlled study.

OBJECTIVES: We analyzed the role of magnesium sulfate (MgSO(4)) supplementation during cardiopulmonary bypass in pediatric patients undergoing cardiac surgery, assessing the incidence of hypomagnesemia and the incidence of junctional ectopic tachycardia. METHODS: We performed a randomized, double-blind, controlled trial in 99 children. MgSO(4) or placebo was administered during the rewarming phase of cardiopulmonary bypass: group 1, placebo group (29 patients); group 2, 25 mg/kg of MgSO(4) (30 patients); and group 3, 50 mg/kg of MgSO(4) (40 patients). RESULTS: At the time of admission to the cardiac intensive care unit, groups receiving MgSO(4) had significantly greater levels of ionized magnesium (group 1, 0.51 + or - 0.07; group 2, 0.57 + or - 0.09; group 3, 0.59 + or - 0.09). Hypomagnesemia before bypass was common (75%-86.2%) and not significantly different among the groups. The proportion of hypomagnesemia decreased significantly at admission to the cardiac intensive care unit in groups receiving MgSO(4) (group 1, 77.8%; group 2, 63%; group 3, 47.4%). Patients receiving placebo (group 1) had a significantly greater occurrence of junctional ectopic tachycardia than groups receiving MgSO(4) (group 1, n = 5 [17.9%]; group 2, n = 2 [6.7%]; group 3, n = 0 [0%]). Age (<1 month), Aristotle score (>4), and history of cardiac failure were associated with junctional ectopic tachycardia. None of the patients with those characteristics in group 3 had junctional ectopic tachycardia. No association was found between study groups and the Pediatric Risk of Mortality score or length of stay in the cardiac intensive care unit. CONCLUSIONS: Supplementation with MgSO(4) during cardiopulmonary bypass seems to reduce the incidence of hypomagnesemia and junctional ectopic tachycardia at admission to the cardiac intensive care unit. This effect seems to be dose related.

The association of renal dysfunction and the use of aprotinin in patients undergoing congenital cardiac surgery requiring cardiopulmonary bypass.

BACKGROUND: The use of large-dose aprotinin during cardiopulmonary bypass (CPB) in adult patients has been linked to postoperative renal dysfunction, but its effect on the pediatric population undergoing complex congenital cardiac operations is not well defined. METHODS: We used a retrospective cohort analysis to evaluate children undergoing cardiac surgery requiring CPB between July 2004 and July 2006. Demographic data and surgical risk quantified by the Aristotle surgical complexity level were analyzed as covariates. Renal dysfunction was defined according to the RIFLE criteria, an international consensus classification which defines three grades of increasing severity of acute kidney injury: risk (Class R), injury (Class I), and failure (Class F) based on serum creatinine values. A univariate and multivariate logistic regression analysis and a propensity score were used to analyze the data. The propensity score was developed using pretreatment covariates associated with the administration of aprotinin. A multivariate logistic regression was then used with the propensity score and intraoperative measures as covariates. A P value <0.05 was considered statistically significant. RESULTS: Among 395 patients who underwent cardiac surgery, 55% received aprotinin and 45% did not. Thirty-one percent of the cohort had previous cardiac surgery; 17% were neonates. According to the RIFLE criteria, 80 of the patients (20.3%) had acute kidney injury in the postoperative period; 53 (13.4%) had risk of renal dysfunction with 23 (5.8%) having injury and four patients (0.7%) having failure. Those receiving aprotinin had a higher incidence of previous cardiac surgery (54.1% vs 5%), sepsis (6.9% vs. 0.0%), heart failure (24.8% vs 12.4%), mechanical ventilation (25.2% vs 2.8%), or mechanical circulatory support (6.0% vs. 0.6%). More patients had an Aristotle level of 4 (26.6% vs 2.8%) and were treated with diuretics (63.8% vs 26.6%), angiotensin converting enzyme inhibitors (21.1% vs 7.9%), milrinone (25.7% vs 4.5%), and inotropic support (16.1% vs 2.3%). Although there was a significant difference in the unadjusted risk of renal dysfunction, adjustment with the preoperative propensity score revealed that there was no association between aprotinin and renal dysfunction (OR 1.32; 95% CI 0.55-3.19). The duration of CPB was the only independent variable associated with the development of renal dysfunction (OR 1.0; 95% CI 1.009-1.014). CONCLUSIONS: Patients who receive aprotinin are more likely to present with preoperative risk factors for the development of postoperative renal dysfunction. However, when associated risk factors are properly considered, the use of aprotinin does not seem to be associated with a higher risk of developing renal dysfunction in the immediate postoperative period in children.